Why did he die?

It is good business practice to have regular independent reviews of processes and procedures to ensure they are fit for purpose and implemented efficiently. Some see this as an unnecessary time consuming overhead, others see the benefits of a review to positively highlight areas to improve and gaps to address. Sometimes it is the smallest of change that can have the biggest positive impact and / or minimise exposure to a risk having a huge adverse impact.

The best way to identify areas that need improving is to nurture an open communication environment where ideas and thoughts can be exchanged and captured. Very often the same idea will be submitted by different people highlighting a real need to address a process detail and minimise a miscommunication risk.


My thoughts and prayers are with the parents of 16 year old boy, who suffered multiple organ failure during a “low risk” operation.


My local newspaper is reporting on the court case hearing of how a surgeon is blaming nurses for the death of the 16 year old. The surgeon allegedly used a sharp instrument known as a trochar instead of a blunt one during minor keyhole surgery and pierced a vein which led to a fatal gas embolism, massive blood loss and cardiac arrest.


The surgeon is being challenged why he failed to notice it was a sharp instrument.


The surgeon instead is blaming the nurses for giving him the wrong instrument. He maintains he had asked for the blunt instrument in the pre-op briefing but was given the wrong instrument during the actual operation.


The nurses state they showed the surgeon three boxed sets of instruments and received instruction it didn’t matter which box is used. The surgeon denied this, claiming only two boxed sets were shown and he did confirm which box is to be used as he was coming out of the hospital coffee shop.


Poor process? Misunderstanding? Miscommunication? Who is telling the truth?


As this is battled out in court to understand what really happened and who is to blame, the sad truth is that a 16 year old died from what was potentially a low risk 40 minute operative procedure. A life is lost no matter what the outcome of the hearing is.


Was there a process in place that these decisions on instruments are to be made and recorded in team briefings? Would a review have highlighted a communication risk and make recommendations to have distinctive colour coded labels differentiating between blunt and sharp instruments and the selected box be signed and dated? Why was a crucial decision made while coming out of a coffee shop?


Could this death have been avoided?


I can’t comment on this case, however there is a lesson for us to learn, which is to carry out regular independent reviews as part of your business operations to identify gaps and areas to improve. In particular look at areas of the business with a critical eye, reviewing all your risk management and mitigation procedures. By doing so, you reduce the risk of errors occurring and your business will operate more efficiently.


An independent reviewer will have a fresh unbiased perspective and spot things that are often not noticed because of routine habits which have formed and endorsed by repetitive behaviours of people delivering.


Errors don’t always result in the loss of life, but why risk not taking all reasonable actions to avoid events, which could potentially have a huge adverse impact on your business and will cost you financially.


If you would like a free guidance note on how to carry out risk reviews, send a request to


This particular court hearing is being reported in the Birmingham Mail by the Investigations Editor, Jeanette Oldham.